Ebola outbreak in DRC and Uganda; an East African public health concern

Abstract On August 21, 2022, healthcare authorities in the Democratic Republic of the Congo (DRC) announced an outbreak of Ebola virus disease in North Kivu Province, bringing the total to 15 outbreaks nationwide. On September 20, 2022, Uganda's authorities declared an outbreak of the Sudan strain of the Ebola virus following a confirmed a case in Mubende district. As of October 6, 2022, the reported numbers of cases were 63, with 29 deaths in Uganda and 1 case with 1 death in DRC, respectively. Ebola virus causes an acute and severely fatal illness, resulting in death within a very short time if left untreated. In addition, these outbreaks in DRC and Uganda pose a major threat to the health and socioeconomic well‐being of the people of East Africa due to multiple cross‐border activities. Adequate preparations need to be made by the healthcare authorities of the nations concerned; the government, healthcare workers, and the East‐African community as a whole have important roles to play in the effective prevention and control of the spread of Ebola virus within and across their borders.

(BEBOV) have been identified as causing outbreaks in East Africa.
The Ebola virus has been detected in blood and other body fluids like saliva, urine, semen, cerebrospinal fluid, tears, and skin swabs. 5,6 The virus is initially acquired through exposure to the body fluids or tissue of infected animals such as bats and nonhuman primates. Transmission of the disease from the infected animals to humans can occur during hunting and consumption of their food products such as meat. Human-tohuman transmission occurs through direct contact with body fluids from EVD patients or objects contaminated with infected body fluids. The virus causes an acute and severely fatal illness, resulting in death within a very short time if left untreated.
Patients with EVD exhibit sudden-onset fever, fatigue, muscle pain, headache, and sore throat, followed by vomiting, diarrhoea, kidney and liver damage, and internal and external bleeding. 7 Ebola outbreaks in DRC and Uganda pose significant threat to the health and socioeconomic well-being of East-African people due to frequent international travel in the region. This results in the disruption of daily agricultural activities, trade, and tourism activities, impacting the lives and livelihoods of the people. 8 Healthcare authorities in the region must be prepared to act.

| EPIDEMIOLOGY OF EVD
The earliest cases of Ebola virus infection were reported in Zaire (now DRC) in 1976 9 Since then, recurrent outbreaks have occurred in Central, Western, and Eastern Africa, 10 as shown in

Key points
• More than thirty Ebola outbreaks have occurred to date, mostly affecting Western and sub-Saharan African countries.
• Following recent Ebola outbreaks in Uganda and the Democratic Republic of the Congo, East-African countries are at a high risk of Ebola outbreak due to high interaction between their citizens.
• Healthcare interventions and efforts employed aimed at stopping previous outbreaks, together with the recommendations presented in this article, are vital for mitigating current Ebola outbreaks and preventing international spread of the virus.

| Efforts
Health authorities in affected countries have attempted to contain the virus, whereby the countries' Ministries of Health have strictly imposed health guidelines on citizens attending both public and private facilities, although Uganda ruled out imposing lockdown as it relies on its capacity to contain the virus as it has done before. 16 Over the past few decades, Uganda has been a relative hotspot of zoonotic disease outbreaks; Ebola

| Recommendations
Controlling the spread of EVD is not only important to DRC and Uganda alone, rather the East African region, Africa and the global community alike. Therefore, the East African region needs to be at alert and be ready to checkmate any route of spread of the virus into its territories.
WHO noted gaps in the DRC's capacity to recover, prepare and respond to outbreaks due to its poor health management systems as contributed to by political unrest and security challenges within the region. 15 Meanwhile, Uganda on the other hand has been assessed to be experienced in responding to EVD. Nonetheless, concerns arise due to the prevailing circumstances which include unavailability of vaccine to the Sudan strain of the virus, poor contact tracing of the index case and its contacts, poor IPC measures of the hospitals that patients with suboptimal symptoms presented to, burial of Ebola patients with a large gathering, and possible unwillingness of individuals to not adhere to IPC measure should the infection escalate higher. All of these set the overall risk at high national and/or regional level, although low at a global level, cross-border infections cannot be ruled out even though the district of epicenter has no borders with the international community. 15,20 We, therefore, recommend the following:

| Healthcare/IPC systems' requirements
Healthcare professionals should immediately report on suspected EVD cases which should include results from laboratory tests.
Monitoring of contacts and management of contact tracing activities should be adequately and sufficiently carried out and proper infection prevention measures (e.g., decontamination, safe burials) should be enabled. 20 Early initiation of supportive treatments should be commenced. There is a need to strengthen surveillance and other response activities to contain the possibility of exponential spread.
Furthermore, health workers, contacts, and contacts-of-contacts should be vaccinated using the Strategic Advisory Group of Experts (SAGE) recommended vaccine, and for those already vaccinated for more than 6 months should be revaccinated if they are among the contacts or contacts-of-contacts of the confirmed case of EVD according to the SAGE. Access to Ebola specific monoclonal antibodies to treat confirmed cases should be provided, as per latest guidelines. 15,20 Moreover, health professionals should be trained on field testing as vaccination and effective testing and surveillance has been proven to be effective in managing and containing spread. 21,22 Other vaccines may not be applicable due to their unavailability and rarity of Ebola occurrence globally. 23

| Government's requirements
The EAC governments should maintain their health system adequately to optimal funding and resource-allocation as these processes keep the systems ready to combat any disease that may occur, rather than being taken up by surprise, which is disastrous to Engagement with communities to support implementation of preventive behavior and to foster acceptance of outbreak response measures is key and can be achieved through government's interaction and collaboration with the media and community leaders.
Moreover, continuous training and retraining of health personnel for early detection, isolation and treatment of EVD cases as well as retraining on safe and dignified burials will go a long way to curtailing cross-infections between health workers and hospital visitors, and the hospital visitors and those they come in contact with, thus alleviating community transmission. 14,15,21 Finally, adequate surveillance should be mounted on the borders to checkmate cross-border infection and also, when necessary, lockdown of the borders and affected districts should be initiated, 14,15 although the regional adherence to the international health regulations should be the first and main line of action as these regulations curb, prevent and shield against the spread of diseases internationally as well as provide measures for a public health response. 25

| The individuals' requirements
Animal products (blood, milk, and meat) should be thoroughly cooked before consumption. Direct or close contact with people showing symptoms of Ebola, especially with their bodily fluids should be avoided to reduce the risk of human-to-human transmission. Animals should be handled with gloves and other appropriate protective clothing if they are to be touched. Appropriate personal protective equipment should be worn when caring for sick patients and regular hand washing with soap and water is necessary after visiting patients in a hospital, as well as after touching or coming into contact with bodily fluids. WHO recommends that "male EVD survivors practice safer sex for 12 months from the onset of symptoms or until their semen tests negative twice for Ebola virus." Additionally, individuals should cooperate with the government and healthcare professionals by adhering to IPC guidelines as well as by reporting any case of EVD to the health professionals. 3,14,21